Provider Demographics
NPI:1386917755
Name:FORT DAVIS DENTAL ASSOCIATES, PLLC
Entity type:Organization
Organization Name:FORT DAVIS DENTAL ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ISAIAH
Authorized Official - Middle Name:PURNELL
Authorized Official - Last Name:MORRISON
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:202-889-8200
Mailing Address - Street 1:2300 GOOD HOPE RD SE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-5147
Mailing Address - Country:US
Mailing Address - Phone:202-889-8200
Mailing Address - Fax:202-889-5891
Practice Address - Street 1:2300 GOOD HOPE RD SE
Practice Address - Street 2:SUITE 3
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-5147
Practice Address - Country:US
Practice Address - Phone:202-889-8200
Practice Address - Fax:202-889-5891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN3045261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC021929400Medicaid